Gait Disorders In The Elderly

Gait disorders include a range of factors such as slowed walking speed and loss of smoothness, symmetry or synchronicity of body movements.

For the elderly, walking, rising from a chair, turning and leaning for independent mobility is required. The walking speed, the time required to get up from a chair, and the ability to tandem stand (stand-a measure of balance with one foot before the other) are independent predictors of the ability to instrumental activities of daily living (eg. B. Shopping, traveling, cooking) and the risk of admission to a nursing home and death.

Gait disorders include a range of factors such as slowed walking speed and loss of smoothness, symmetry or synchronicity of body movements. For the elderly, walking, rising from a chair, turning and leaning for independent mobility is required. The walking speed, the time required to get up from a chair, and the ability to tandem stand (stand-a measure of balance with one foot before the other) are independent predictors of the ability to instrumental activities of daily living (eg. B. Shopping, traveling, cooking) and the risk of admission to a nursing home and death. Walking without assistance requires adequate attention and muscle strength and an efficient motor control to coordinate sensory input and muscle contraction. Tips and risks The walking speed, the time required to get up from a chair, and the ability to stand tandem are independent predictors of the ability to instrumental activities of daily living and the risk of admission to a nursing home and death. Normal age-related changes of the aisle Some elements of the aisle do not change normally with aging, others. The walking speed (speed walking) remains stable until about 70 years, it then falls by about 15% per decade during normal walking and by 20% per decade during fast walking off. The walking speed is a strong predictor of mortality – as meaningful as the number of chronic diseases and hospitalization of an elderly person. At the age of 75 years dying persons walking slowly ? 6 years earlier than those who go at normal speed, and when people go ? 10 years earlier that quickly. from the walking speed increases because older people with the same speed (cadence) make shorter steps. The most likely reason for the shortened step length (distance from a heel to the next) is a weakness of the calf muscles which drives the body forward; the strength of the calf muscles is significantly reduced in the elderly. However, older people seem to compensate for their declining strength in the calf muscles, by using their Hüftebeuger and extensors more than young adults. The cadenza (indicated as steps / min) does not change with aging. Everyone has a preferred cadence that is related to leg length and usually represents an energy-efficient rhythm. Great people make longer strides with lower cadence, small people make shorter steps at a faster cadence. The time in the double state (i. E., The time in which both feet on the ground when walking are-stable position for moving the center of gravity to the front) increases with age. The percentage of time in a double sized enterprises range from 18% in young adults up to ? 26% in healthy older people. A prolonged time in a double state reduces the time that the swing leg to go forward, and shortens the stride. In older people, the time may even extend in a double booth when they go on uneven or slippery surfaces when they have balance problems or if they are afraid of falling. You can look as if they were on ice. The walking attitude changes only slightly with aging. Older people walk upright without lean forward. However, older people go with a stronger anterior (downward) pelvic rotation and increased lumbar lordosis. This position change is usually based on a combination of weak abdominal muscles, stiff hip flexors and increased abdominal fat. Older people also go with about 5 ° laterally screwed legs (toes), possibly due to a failure of internal rotation of the hip or to increase lateral stability. The foot space while walking remains unchanged with age. Joint mobility is changing slightly with aging. The plantar flexion of the ankle during the late phase of contact with the ground (just before the rear foot apart) is reduced. The entire movement of the knee remains unchanged. Hip flexion flexion and extension are unchanged, the hip adduction, however, increased. The pelvic movements are restricted in all planes. Gang anomalies causes a number of diseases can contribute to dysfunctional or unsteady gait. These comprise in particular neurological diseases Musculoskeletal diseases (for. Example, spinal stenosis [Lumbar Spinal Stenosis]) Causative neurological disorders are dementia (dementia), movement and cerebellar disorders (disorders of the motor system and the cerebellum), and sensory or motor neuropathy (hereditary neuropathies) .Manifestationen There are many cases of transition anomalies. Some support the adoption of certain causes. (Demonstrations on video of selected abnormal gaits are available here for illustration.) The loss of symmetry and temporal coordination of movement between the left and right side usually indicates a fault. A healthy body moves symmetrically; Stride length, cadence, body movements and ankle, knee, hip and pelvic movements are the same on the right and the left. A regular asymmetry occurs in unilateral neurological diseases or muskuloskelettaen to (z. B. claudication due to a sore ankle). Unpredictable or highly variable step frequency, length, or width indicates a failure of the motor control due to a transition cerebellar or frontal lobe syndrome on. Difficulty in initiating or maintaining the transfer can occur. If the patient initiate the transition, can make their feet appear as if they were glued to the floor, typically because the patients do not shift their weight to one foot, so that the other can move forward. This problem can stand for an isolated transition Introduction disorder, Parkinson’s disease or frontal or subcortical disease. Once the transition is initiated, the steps continuously and with little variability in the time sequence should be. Freezing, stopping or nearly stopping point usually on a cautious transition to overthrow the fear or a frontal gait disturbance out. Shuffle is not normal (and a risk factor for tripping). Retropulsion means going in transition Introduction backwards or fall backwards while walking. It can occur in frontal gait disturbances, Parkinsonism, CNS syphilis and progressive supranuclear palsy. A foot drop causes a tightening of the toe or a stepper transition (i. E. Excessive raising of the leg, in order not to hook with the toe). It can result of tibialis anterior weakness (e., Caused by trauma to the peroneal nerve at the knee lateral or peroneal mononeuropathy usually associated with diabetes) (, a spasm of the calf muscles gastrocnemius and soleus ) or a lowering of the pelvis due to a weakness of the proximal muscles (on the object side, in particular the gluteus medius). A low Fußschwung (z. B. due to a reduced flexion of the knee) may be similar to the foot drop. A short stride length is non-specific and can the fear of falling or a neurological or musculoskeletal problems reflect. The side with the short stride length is usually the healthy side and the short step is usually based on a malfunction of the other (problematic) leg during the stance phase. A patient with a weak or aching left leg spent less time while standing on the left leg, and generates less power in order to move the body forward, resulting in a shorter oscillating period for the right leg and a shorter right step , A normal right leg has a normal single life what a normal oscillation time for the abnormal left leg due and a greater stride length of the left leg in comparison to the right. Broadbased passage (enlarged step width) is determined at the observation of the patient’s response over a base with 30 cm tiles. The corridor is considered to be broad-based if the outside of the patient’s feet do not remain within the tile width. By walking speed decreases, the step width increases slightly. Broadbased transitional may be caused by cerebellar disorders or bilateral knee or hip disorders. A variable step width (roll to one or the other side) indicates a lack of motor control, which may be due to frontal subcortical or gait disturbances. Circumduction (moving the foot when going forward in an arc instead of a straight line) occurs in patients with weakness of the pelvic musculature or difficulty in bending of the knee. Spasticity of the extrinsic muscles of the knee is a common cause. Forward inclination may occur with kyphosis and Parkinson’s disease or disorders, Parkinson-like features with dementia have (in particular, vascular dementia, and dementia with Lewy bodies). Festination is a progressive acceleration of steps (usually with forward tilt), the patients begin to run if necessary, to keep from falling. Festination can happen with Parkinson’s disease and rarely as a side effect of dopamine antagonists (conventional and atypical antipsychotics). A lateral inclination of the trunk, which refers consistent and predictable on the side of the supporting leg can be a strategy, joint pain due to arthritis in the hip or, less commonly, to reduce in the knees (antalgischer gear). In hemiparetischem course of the hull to the strong side may be inclined. In this pattern, the patient tends to lift the pelvis on the opposite side, so that the spastic leg (which can bend the knee not) during the swing phase the ground untouched. Irregular and unpredictable hull instability can be caused by cerebellar, subcortical or basal ganglia dysfunction. Deviations from the path are strong indicators of deficits in motor Steruerung. The arm swing can be reduced or absent in Parkinson’s disease and vascular dementia. Disorders of Armschwungs may also be adverse effects of dopamine antagonists (conventional and atypical antipsychotics). Clarification The goal is to determine as many potential factors for gait disorders. A performance-based assessment tool for mobility can be helpful (Performance-based evaluation of mobility), as well as other clinical tests (eg. As a screening for cognitive testing of patients with gait disturbances that might arise from frontal lobe syndromes). Performance-based assessment of the mobility component findings score * Clinical significance initiating the transfer (after the patient was asked to go immediately) Any hesitation or more attempts to start 0 M. Parkinson Insulated transition Introduction disorder (stroke or dementia) Frontal gait disturbance Without hesitation 1 Stride length and height right (right swinging leg) does not happen the left foot at the step or leaves the floor at the step completely untouched 0 arthritis foot problem stroke happens the left foot 1 The floor remains completely untouched one step length and height left (left swinging leg) not pass the right foot at the step or leaves the floor at the step completely untouched 0 arthritis foot problem stroke passes the right foot 1 The floor remains completely untouched one step symmetry stride right and left are not the same (estimated) 0 Unidirectional M uskuloskelettales or focal neurological deficit stride equal right and left (estimated) 1 Step Continuity Stopping or discontinuity between steps 0 Frontal gait disorder fear of falling steps appear continuous one way (estimated in relation to 30 cm wide B odenfliesen; observed deviation of a foot about 3 m) Significant deviation 0 Frontal gait disturbance Mild to moderate deviation or using a walking aid 1 Straight without walking aids 2 Hull Significant fluctuation or using a walking aid 0 cerebellum, subcortical and basal ganglia dysfunction Antalgischer passage (Arthitis in hips or knees ) No wavering, but bending knees, back pain or arms spread while walking one afraid to fall no wavering, no diffraction, no use of arms and no use of a walker 2 Step width heel when walking far apart 0 hip disease cerebellar disease NPH Heels touching leg walking nearly 1 * is the perfect score 12. A score <10 is generally associated with restrictions on the function-related mobility. Adapted from Tinetti M: Performance-oriented assessment of mobility problems in elderly patients. Journal of the American Geriatrics Society 34: 119-126, 1986; used with permission. The assessment is best dealt with in four parts: Discuss the problems, fears and goals of the patient in terms of mobility observing the response with and without aid (if safe) evaluation of all components of the transition (Performance-based evaluation of mobility) Continue observing the passage with knowledge of the patient's medical history through components In addition to the standard medical history elderly patients should be asked about gang-related problems. First, they are asked to difficulty walking and / or with the balance and to open questions, if they have fallen (or afraid to overthrow). Then the specific skills are assessed; to include whether the patient can climb stairs and go down if they can stetzen on a chair in a shower or bath and stand up again and if they shop if necessary and cook and do the housework. If they report any difficulties, the details at the beginning, duration and course are determined. The history of neurological and muskuloskelettalker complaints and known diseases wichtig.Körperliche investigation be carried out a thorough physical examination, focusing on the musculoskeletal system (evaluation in patients with joint diseases: Medical Examination) and the neurological examination (Introduction to neurological examination). The strength of the lower limb is judged. The proximal muscle strength is tested by the patient rise from a chair without using your arms. The strength of the calf muscles will be determined by the patient standing in front of a wall, place palms of her hands on the wall and rise on their toes, first with both feet and then with one foot. The strength of the hip internal rotation of the gear is beurteilt.Beurteilung A routine assessment of the transfer can be performed by a general practitioner; an expert may be needed for complex gait disorders. For assessing a straight hallway without disturbing factors or obstacles and a stopwatch are needed. Patients should be prepared for the examination. They should be required to wear knee-free pants or shorts and are informed that any more observations are needed, they can rest but when they are tired. Auxiliary devices provide stability, but also affect the transition. The use of Gehböcken often leads to a flexed posture and discontinuous transition, especially in Gehböcken without wheels. If it is safe to do so, the doctor should allow the patient to walk without aids, but remain near him or take him with the aid of a belt for safety. Use the patient a walking stick, the doctor can go with them on the side of the stick or hold her arm and go with them. Patients with suspected. peripheral neuropathy should touch the forearm of the doctor walking. improved the speed in this assistance, proprioception is used from the arm to supplement the lack of proprioception from the leg; Such patients benefit, transmitted normally from the use of a cane, the information on the nature of the surface or soil to the hand holding the stick. The balance is assessed by determining the time that may be the patient's both feet in tandem stand (heel to toe) and a foot (on one leg); normally are ? 5 s. The walking speed is measured with a stopwatch. The time is stopped, in which the patient (preferably 6 or 8 m) to travel a predetermined distance with the preferred speed. The test may need to be repeated if the patient go as quickly as possible. The normal walking speed in healthy elderly ranges from 1.1-1.5 m / s. The cadenza is determined as steps / min. The cadence varies with the leg length of about 90 steps / min for large adults (1.83 m) to about 125 steps / min for small adults (1.5 m). The step length can be determined by 10 by measuring the distance via 10 steps, and dividing that number. Since smaller people make shorter steps and foot size is directly related to body size, the normal step length is 3 foot lengths and an abnormal stride <2 foot lengths. A rule of thumb says that if at least 1 foot length between the steps of the patient is visible, the step length is normal. The step height can be judged by observing the oscillating foot; it touches the ground, v. a. in the middle of the swing phase, patients may stumble. Some patients with fear of falling or a cautious transition to push their feet deliberately on the soil surface. This gait can be safe on a smooth surface, but is risky when walking on carpets because patients may stumble. Asymmetry or variability of gait rhythm can be detected by the doctor himself telepromting at each step of the patient "dum..dum..dum". Some doctors hear the passage rhythm better than him sehen.Tests Sometimes tests are needed. Frequently, a CT scan or MRI of the brain, in particular in case of insufficient transition initiation, chaotic cadence or the image of a very rigid gear. These tests help to identify lacunar infarcts, diseases of the white matter and focal atrophy and contribute to the determination of whether a normal pressure is to be considered. Treatment resistance training balance training aids Although it is important to determine the reason for transition anomalies interventions to change in the program are not always displayed. A slowed, aesthetically divergent transition may allow the elderly person to go safely and without assistance. However, some interventions can lead to an improvement; This information can include physical activity, balance training and tools (treatment of gait abnormalities). Treatment of gait disorders Frequent troubleshooting Comments bone structure Kyphotic posture due to compression fractures of the thoracic spine or poor posture chest expansion, rotation of the shoulder, head to the breast of osteoporosis treatment to prevent new fractures A compression fracture can be diagnosed by X-ray and osteoporosis by bone density measurement. Leg length differences heel lift normally does not amount to the correction of the heel lift 100%. Heavy genu varus or valgus orthotics, braces, strengthening the quadriceps The criteria for knee replacement should be reviewed. Fußanomalie or pain hallux valgus (bunion) loss of the longitudinal arch orthotics, foot care, customized shoes tests ever done in plantar neuropathy with nylon monofilaments to detect the risk of plantar ulcerations. Range of motion of the joints Decreased internal rotation of the hip stretching the adductors, abductors strengthen Trying to improve the internal rotation stretch, is not usually effective, but can prevent a further limitation of range of motion. Decreased hip extension stretching the hip flexors, hip extensors strengthening of a thoracic extension in the prone position is often recommended. Decreased dorsiflexion of the ankle stretching the calf muscles, the heel height of the shoes is reduced. Hallux rigidus (loss of dorsiflexion of the big toe) pedicure or referral to an orthopedic surgeon An orthosis should be considered. Muscle weakness hip extension exercises to get up from a chair tests to get up from a chair can be helpful in diagnosis. Weak knee extension exercises to get up from a chair, knee extension with sand bags at the ankles, squat tests to get up from a chair can be helpful in diagnosis. Weak plantar flexion of the ankle heel lift (using the body weight) in order to increase the resistance in the heel lift, the patient can wear a jacket, a backpack, or a belt with weights; maybe they need to stabilize against a wall. Weak dorsiflexion of the ankle muscle strengthening (z. B. toes added), ankle-foot orthoses for foot drop Patients lay sandbag weights on her metatarsal. With his back to the wall for safety reasons, patients rise on the heels (d. E. They raise the toes from the ground). Weak hip abduction abduction with weights on the ankles, lying sideways on the floor - Sensory Systems position sense or balance are reduced or impaired when the eyes are closed during Romberg's test Appropriate footwear Vitamin B12 levels should be checked. Reduced or impaired plantar tactile sensation measured with Semmes-Weinstein monofilaments according Appropriate footwear The patient should be ascertained for diabetes and alcohol abuse. Lightheadedness or dizziness dizziness (dizziness), and dizziness (vertigo): Therapy - Motor control / balance tandem stand or leg stance <5 s or 360 ° rotation (both to the right and to the left) requires> 10 steps or patient is uncertain during the rotation balance training , incl. static and dynamic balance, tai chi, or equivalent to vitamin D supplementation (1000-2000 IU once daily) in frail elderly patients with limited sun exposure reduces the risk of falls and injury. Anteversion bradykinesia leg hypertension Parkinson’s characters Physiotherapeutisches training for the maintenance or improvement in motor control / balance with a CT or MRI lacunar infarcts or diseases of the white matter can be recognized. The vitamin B12 levels should be checked. Physical and cardiovascular fitness

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